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Hindawi Publishing Corporation
Journal of Obesity
Volume 2013, Article ID 837989, 5 pages
http://dx.doi.org/10.1155/2013/837989

Review Article
The Impact of Bariatric Surgery on Psychological Health
Jeremy F. Kubik,1 Richdeep S. Gill,2 Michael Laffin,2 and Shahzeer Karmali2,3
1

Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T5H 3V9
Department of Surgery, University of Alberta, Edmonton, AB, Canada T5H 3V9
3
Royal Alexandra Hospital, Room 405, Community Services Center 10240 Kingsway, Edmonton, AB, Canada T5H 3V9
2

Correspondence should be addressed to Shahzeer Karmali; shahzeer@ualberta.ca
Received 29 January 2013; Accepted 12 March 2013
Academic Editor: Lien Goossens
Copyright © 2013 Jeremy F. Kubik et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Obesity is associated with a relatively high prevalence of psychopathological conditions, which may have a significant negative
impact on the quality of life. Bariatric surgery is an effective intervention in the morbidly obese to achieve marked weight loss
and improve physical comorbidities, yet its impact on psychological health has yet to be determined. A review of the literature
identified a trend suggesting improvements in psychological health after bariatric surgery. Majority of mental health gain is
likely attributed to weight loss and resultant gains in body image, self-esteem, and self-concept; however, other important factors
contributing to postoperative mental health include a patient’s sense of taking control of his/her life and support from health care
staff. Preoperative psychological health also plays an important role. In addition, the literature suggests similar benefit in the obese
pediatric population. However, not all patients report psychological benefits after bariatric surgery. Some patients continue to
struggle with weight loss, maintenance and regain, and resulting body image dissatisfaction. Severe preoperative psychopathology
and patient expectation that life will dramatically change after surgery can also negatively impact psychological health after surgery.
The health care team must address these issues in the perioperative period to maximize mental health gains after surgery.

1. Introduction
2

Obesity, as defined by a body mass index (BMI) > 30 kg/m ,
is a chronic disease that is increasing in prevalence in adults,
adolescents, and children. It has been described by the World
Health Organization as a global epidemic [1]. In addition,
obesity is a significant risk factor for numerous comorbidities,
including heart disease, diabetes, hypertension, dyslipidemia,
stroke, atherosclerosis, and specific types of cancer [2]. It is
also associated with overall increased mortality and decrease
in lifespan by ten years [3]. Obese individuals have an
increased risk of psychological distress, disordered eating,
and impaired health-related quality of life (HRQoL). As
the severity of the obesity rises, so does the severity of
the medical complications and the mortality risk. This is
important because extreme or morbid obesity, defined as BMI
> 40 kg/m2 , is one of the most rapidly growing subgroups of
obesity.
Weight loss of 5 to 10% has been associated with significant reductions in comorbidities and mortality [4]. These
numbers can be achieved through conventional lifestyle and

pharmacologic interventions for the mild to moderately
obese; however, such interventions are quite limited in morbid obesity. Currently, bariatric surgery has been shown in
the literature to be an effective treatment for morbid obesity
as part of an overall weight management strategy. While
the efficacy of this treatment modality is often expressed as
postoperative weight loss, an important and often overlooked
outcome is an evaluation of the impact of surgery on psychological health. This is an important outcome measure, as it
may contribute to the patient’s overall concept of wellbeing.
This review assesses the literature on the impact of bariatric
surgery on psychological functioning of morbidly obese
patients.

2. Methods
A systematic review of the current literature was conducted to
evaluate the impact of bariatric surgery on the psychological
health of obese patients. The search for relevant articles was
conducted using both MEDLINE and PubMed databases
with the following search terms: morbid obesity, bariatric

2
surgery, psychology, psychological health, and mental health.
Studies were not discriminated based on the type of bariatric
procedure performed as all methods appear to be effective
in treating morbid obesity. Relevant pediatric studies were
also reviewed. A total of 27 articles were evaluated, including
6 literature reviews, 2 systematic reviews, and 19 primary
studies.

3. Results and Discussion
3.1. Psychological Health in Obese Individuals. A high prevalence of psychological comorbidities exists in obese patients,
particularly mood disorders, anxiety, and low self-esteem.
Extremely obese individuals are almost 5 times more likely
than their average weight counterparts to have suffered
from a major depressive episode in the past year [5]. The
correlation between these two conditions is multifactorial.
Body image dissatisfaction, commonly seen in obese patients,
is heavily correlated with symptoms of depression [6], and
this is particularly true in women, likely secondary to societal
emphasis on the female physique. Obese individuals are also
subjected to prejudice and discrimination, which is likely
to cause or aggravate depression [7, 8]. Several studies have
shown that these individuals have lower household incomes,
struggle to find higher education, and are less likely to be
married as compared to their nonobese peers of similar
intellectual aptitude. Furthermore, repeated failed attempts
to lose weight are common in this population and are likely
to aggravate depressive illness, hopelessness, and poor selfesteem [9], perhaps contributing to further weight gain.
Interestingly, 25–30% of bariatric patients report depressive
symptoms at the time of surgery and up to 50% report a
lifetime history of depression [5].
Similar to other obesity-related complications, psychological health appears to worsen with the increasing severity
of obesity. Bariatric patients seeking surgery have a higher
prevalence of psychological distress compared to other obese
patients who do not seek surgery [10]. They are often driven
to pursue surgery due to a distressing event. One study
found that 38% of patients met diagnostic criteria of at least
one Diagnostic and Statistical Manual of Mental Disorders(DSM-) IV axis I disorder and 29% met criteria for one or
more DSM-IV axis II disorders at the time of preoperative
evaluation [11]. Another study suggests that obese individuals
seeking medical treatment for obesity (pharmacotherapy
or surgery) are more likely to suffer from psychological
distress compared to their peers of similar BMI who seek
behavioral therapy and dietary restriction [12]. Finally, the
deterioration of psychological health in the obese population
has also been attributed to the development of obesityrelated comorbidities such as cardiovascular disease and type
2 diabetes mellitus [13–15].
3.2. Bariatric Surgery for Weight Loss. Mild-to-moderate
obesity (BMI 30–40 kg/m2 ) may demonstrate some improvement in the short-to-medium term with lifestyle changes
(dieting and exercise) and behavior therapy. As these treatments are typically ineffective for severe obesity, the literature
suggests that bariatric surgery is the most effective treatment

Journal of Obesity
for weight loss and maintenance in the morbidly obese
individual. In order to be eligible for surgery, the patient must
have failed previous nonsurgical weight loss measures and
either have a BMI > 40 or have a BMI > 35 in the presence
of severe obesity-related comorbidity. The primary goal of
bariatric surgery is for the patient to not only lose weight, but
to also maintain the loss. A secondary goal is for the patients
to change their eating behavior and engage in frequent
exercise to promote a greater lifestyle change.
Bariatric procedures work by restricting the amount of
oral intake and/or causing malabsorption. The primary
bariatric procedures include laparoscopic adjustable gastric
banding (LAGB), which is purely restrictive, whereas Rouxen-Y gastric bypass (RYGB) employs a combination of restrictive and malabsorptive approaches. Other procedures
include laparoscopic sleeve gastrectomy (LSG) and biliopancreatic diversion. Bariatric procedure selection is based on a
thorough evaluation of the patient’s medical, psychological,
and social issues.
A meta-analysis of bariatric surgery revealed that the
mean percentage of excess weight loss was 47.5% for patients
who underwent gastric banding and 61.6% for those who
underwent gastric bypass [16]. Weight loss tends to stabilize around two years postoperatively, while small amounts
of weight regain can occur in the third year [5]. More
importantly, numerous studies have determined that surgical
interventions lead to significant reversal of many obesityrelated comorbidities, including type 2 diabetes, metabolic
syndrome and adjusted long-term mortality [17–19]. Not only
has bariatric surgery demonstrated significant and sustained
weight loss, it is also a cost-effective intervention for severely
obese patients [20].
3.3. Postoperative Psychological Health. Despite significant
measurement heterogeneity evaluating the impact of weight
loss surgery on psychological change, numerous studies and
comprehensive reviews have reported overall postoperative
improvement in depressive symptoms, self-esteem, healthrelated quality of life, and body image [21–24]. A prospective, well-controlled study of Swedish Obese Subjects (SOS)
involving 4047 obese patients provides the best assessment
of postoperative mental health change. Patients reported a
significant decrease in depression and anxiety in the year
after surgery compared to obese controls treated with diet
and exercise counseling [25]. A systematic review of 40 studies from 1982–2002 reinforced these findings as consistent
improvement of axis I psychiatric disorders of the DSM
(particularly depression and anxiety) was reported postoperatively [22]. These psychological gains reflect those found in
patients who have achieved weight reduction with behavioral
or pharmacologic treatment. Furthermore, postoperative
weight regain has been associated with increased depression
[21]. Taken altogether, this suggests that psychopathology
in the morbidly obese is likely attributable to their obesity
as opposed to their underlying character. The magnitude of
mental health gain may also be related to the amount of
weight loss after surgery [25–27].
It is likely that postoperative improvements in psychological health can be attributed to more than just weight loss

Journal of Obesity
and self-concept as a result of weight loss. Mental health
gains have been reported by patients who fail to lose weight
and by patients within a few weeks after surgery, prior to
any significant weight loss [28]. This may be attributable to
patients taking an active role in changing their lives, despite
still being overweight. Preoperative psychopathology also
plays an important role as patients may report an inflated
change in mood soon after surgery because they are relieved
of the distressing event that initially prompted them to seek
surgery [12].
Although overall improvements are found postoperatively, there remains a significant minority of patients who
either report dissipation in mental health gains long-term
after surgery or no psychological benefit at all [21, 24].
Preoperative patient expectations that life will dramatically
change after bariatric surgery may have a negative impact
on psychological health if these results are not met, even if
significant weight loss is achieved. Moreover, some patients
realize that certain presurgical problems persist after surgery,
which may disappoint them because they cannot attribute
underlying emotional disturbance to their weight. Furthermore, patients may have difficulty coping with negative life
events that they were previously able to attribute to their
obesity.
On the long term, some studies report decreases in levels
of depression up to two [29] and even four years postoperatively [30], whereas others report initial improvement
followed by decline. The latter seems to correspond to initial
weight loss followed by regain or weight stabilization [21].
Initial improvements after surgery may be due to positive
reinforcement from frequent post-op clinic visits [31], and as
the frequency of followup visits decrease, as does the patient’s
psychological state. Although more research is needed to
determine mental health status several years after bariatric
surgery, followup must be conducted long term after surgery
to assess and support the patient’s psychological well-being.
It is of note that although several studies have reported
increased rates of suicide in their patient population after
surgery, there is significant variation in cohort characteristics
and length of followup in these studies. Thus, it is difficult
to adequately compare suicide rates in postbariatric patient
populations to the general population [22].
3.4. Self-Concept and Personality. Self-concept refers to a
patient’s perception of “self ” and includes several important
characteristics with respect to the bariatric population: selfesteem, body image, self-confidence, and sense of attractiveness, and assertiveness. Although these factors have not been
studied in a standardized or systematic fashion, a review
of the literature seems to suggest that weight loss surgery
improves self-esteem, self-confidence, and expressiveness
[21]. These changes appear to be correlated with major
improvements in body image and weight-loss satisfaction
after surgery [21]. However, residual body image dissatisfaction due to increasing and/or sagging skin has been
reported after surgery in as high as 70% of patients in one
particular study [32], even if 90% were pleased with their
overall appearance. Patients who reported greater satisfaction
after surgery were found to have lost less weight than their

3
dissatisfied counterparts, likely because their “skin problems”
were less pronounced. Bariatric surgeons must therefore
counsel their patients prior to surgery regarding common
postoperative skin changes in order to mitigate psychological
distress. As patients seek out body-contouring surgery to
address skin issues, plastic surgeons also play an important
role in discussing the benefits and limitations to plastic
surgery.
No definitive conclusions can be made evaluating the
impact of obesity surgery on personality disorders. Favouring
improvement, a review noted reduction in neuroticism,
defensiveness and immature identity with an increase in
discipline in patients after surgery [24]. On the other hand,
this review found certain studies that reported no significant
changes in personality pathology, perhaps because these
disorders manifest early in life and are quite stable and
resistant to environmental change.
3.5. Eating Behavior. Eating behavior disorders are fairly
common among the obese population, particularly binge
eating disorder (BED), which occurs in 5–15% of patients
who present for surgery [5]. Postsurgical data evaluating
eating behavior is difficult to assess primarily because of
variability in the definition of binge eating employed by
different studies. This contributes to inconsistencies as to
whether psychological aspects of binge eating can be cured
by bariatric surgery [33]. Regardless, a review suggests that
binge eating behavior may be alleviated after surgery, likely
because patients are required to follow strict small meal diets
postoperatively [24]. Following this regimen is likely to lead
to normalization in eating pattern on the long term.
However, many patients continue to suffer from psychologically distressing eating behaviors after surgery, specifically those with preoperative eating disorders [24]. This
includes rigid eating control due to a continuous fear of
weight regain. Although consuming unusually large amounts
of food becomes near physically impossible after bariatric
surgery, some patients report loss of eating control and
claim they would continue to overeat if it were not for early
satiety and vomiting. Interestingly, a recent comprehensive
interview study of eating behavior two years after surgery
identified a subset of patients who reported vomiting for
weight and shape reasons [34]. This is clinically important
because postoperative vomiting has long been thought of as
involuntary and secondary to the physical consequences of
surgery.
3.6. Pediatric Obesity and Bariatric Surgery. Rates of extreme
pediatric obesity are increasing at an alarming rate, and
as the prevalence of obesity rises, as does the prevalence
of comorbidities such as diabetes, obstructive sleep apnea,
steatohepatitis, and cardiac disease. These complications were
once thought of as “adult-onset” diseases. With respect
to psychosocial comorbidity, it comes as no surprise that
that severely obese adolescents are a particularly vulnerable
group. Obese children suffer from alienation, poor selfesteem, body dissatisfaction, depressive symptoms, loss-ofcontrol eating, unhealthy weight control behaviors, and
impaired social relationships [35, 36]. In one study, HRQoL

4
in severely obese children and adolescents was reported just
as low as in children diagnosed with cancer [37]. Finally, the
risk of psychological distress appears to increase with age and
is greater among girls than boys [38, 39].
Initial treatment of pediatric obesity relies on a familycentered approach to improve food quality and physical
activity while reducing caloric intake [40]. Although there
is limited data evaluating the long-term effects of dietary
and behavioral treatments in obese pediatric patients, these
interventions generally have poor success. When these
interventions are combined with pharmaceuticals, weight
management appears to improve [41]. If a severely obese
pediatric patient with comorbidities fails initial treatment,
bariatric surgery can be considered, even though long-term
risks have yet to be determined [42]. A systematic review
of the literature reveals that weight loss after surgery in
adolescents has been comparable to that in adults, with an
average of 50–60% of excess weight lost in the first year and
up to 75% by the end of the second year [42]. Absolute BMI
reduction in adolescents postsurgery is approximately 35%,
leading to improvements and resolution of hypertension,
insulin resistance, type 2 diabetes, and dyslipidemia [42].
Current research, though limited, reveals that bariatric
surgery may also lead to important psychological benefits
in the pediatric population. Recent studies have reported
improvements in psychological health (depression, anxiety,
and self-concept) after RYGB for patients four months [43]
and up to two years postoperatively [44]. As with adults,
changes in mental heath seem to parallel weight change and
stability, yet a subset of the patient population maintained
health gains despite still being overweight or obese. Zeller
et al. [44] suggest that a change in weight, reduction of
comorbidities, or a patient’s revitalized self-concept may
override the patient’s concern with actual weight status when
assessing psychological health.

4. Conclusions
Bariatric surgery is a clinical and cost-effective treatment
strategy for the morbidly obese. Although the impact of
bariatric surgery on psychological health is often overshadowed by the significant reduction in physical comorbidities,
it is important to investigate the former as obesity is strongly
correlated with psychological distress and may have a marked
effect on quality of life.
This review reveals overall improvements in psychopathology, depressive symptoms, eating behavior, body image,
and HRQoL following bariatric weight loss surgery. In
addition, preliminary studies suggest that mental health
gains are also achieved in the obese pediatric population.
These improvements are most consistent with weight loss
and subsequent sequelae such as change in self-esteem, selfconcept, and body image. Postoperative psychological health
is also influenced by the patient’s sense of taking control of
their life and by physical and mental support from health care
staff.
Not all bariatric patients, however, experience mental health gains from weight loss surgery, which is likely
attributable to patients’ reactions to common undesired

Journal of Obesity
physical outcomes postsurgery: lack of weight loss, weight
regain, and undesirable skin changes. Patients’ expectations
that bariatric surgery will undoubtedly change their life may
also set them up for psychological failure if expectations are
not met. The health care team must recognize that the negative reactions to adverse events may be accentuated in obese
patients seeking surgery as they have a higher prevalence of
psychological distress compared to obese individuals in the
community. The preoperative evaluation is therefore critical
to identify and follow those at risk of persistent or worsening
psychopathology after surgery. It will also serve to detail the
necessity of postoperative behavioral and lifestyle change and
its effect on weight loss. Long-term intensive postoperative
followup to evaluate and support lifestyle change can have
a tremendous effect on weight loss as well as physical and
psychological comorbidities.

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